American Steamship Company/Liberty Steamship Company 2019americansteamship.com/pdfs/2019/2019 ASC...
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American Steamship Company/Liberty Steamship Company 2019 Physical Cover Letter with Physical Exam Protocol Required Components Physical Exam using NEW CG-719K form ...................... (employee MUST take the completed ORIGINAL) Height, Weight & Vital Signs BMI Vision (Near, Far, & Color) Urine Dipstick Hearing ...................................................................... If Whisper Test not passed, proceed to Audiogram ONLY Utility men, Conveyer men, Wiper/Gate men..... Pulmonary Function Testing ONLY Food Handlers/Galley Workers.......................... 1. TST (Mantoux) or T-Spot or QuantiFERON Gold-TB Blood Test 2. Hepatitis A Vaccine (if not yet vaccinated) 3. Document free from communicable disease on Addendum Company pays for ONLY these components. Employees are financially responsible for ANY additional testing listed below Annual Certification Requirements Your annual physical will be reviewed by St. Luke’s Occupational Health. If you have any of the conditions listed to the right, please submit the appropriate additional information listed with your physical exam. BLOOD DISORDERS Annual follow-up with primary provider CBC CIRCULATORY MI/CAD Annual cardiology consult EST every 2 years (CABG- every 2 yrs after 5) Rhythm disorders requiring continuous treatment Annual cardiology consult INR records for last 30 days (if applicable) Valvular disease Annual cardiology consult Aortic stenosis - echo annually Aortic regurg - echo every 2 years INR records for last 30 days (if applicable) Congestive Heart Failure Annual cardiology consult Annual echo Aneurysms Annual cardiology or vascular surgery consult Annual US Peripheral vascular disease Annual follow-ups with primary physician \ DVT Annual follow-up with primary physician INR records for last 30 days (if applicable) Defibrillators Cardiology consult note within last 12 months Echocardiogram or other method to measure EF Exercise Cardiac Stress Test within last 12 months ENDOCTRINE Diabetes Annual follow-up with primary physician HgA1C < 90 days old Thyroid disease Annual TSH EYES Glaucoma - Annual ophthalmology consult GASTROINTESTINAL Hepatitis Annual follow-up by primary provider Annual LFT’s (for Hepatitis B and C until “cured”) cont. GASTROINTESTINAL continued Gastrointestinal pathology requiring continued treatment Annual gastrology or internal medicine consult HIV Annual follow-up with primary provider Viral load CD4 count KIDNEY DISEASES Annual follow-up with primary provider Annual serum Creatinine MUSCULOSKELETAL Statement from examining provider about function of affected area NEUROLOGIC TIA, cerebral hemorrhage, intracranial aneurysm, cerebral thrombosis Annual neurological consult for 5 years post event Deteriorating neurological conditions Annual neurology consult to asses function Seizure disorders Annual neurology consult addressing control of seizure disorder PSYCHIATRIC All conditions except mild depression- annual mental health provider consult with statement of control of condition and efficacy and tolerance of medications. Substance abuse Statement from primary provider addressing control of substance abuse. RESPIRATORY Asthma (requiring ER treatment in last 2 years) Pulmonology consult Pulmonary Function Test Chronic bronchitis/ Emphysema/ COPD Annual Pulmonary Function Test and pulse oximetry Obstructive Sleep Apnea Annual follow-up with primary care provider documenting efficacy of treatment TUBERCULOSIS (history of active or latent) Annual review of symptoms by primary care provider Results FAX (218-249-6828) or e-mail ([email protected]) Please do NOT Fax AND e-mail 1. ALL medical information required for this exam. 2. Signed Release of Information to Attn: Medical Records, St. Luke’s Occupational Health (Call 218-249-6822 with ANY questions) Billing: Billing for Required Components ONLY to ............................. Attn: Mary Banks P: 716-635-1371 American Steamship Company 500 Essjay Rd Williamsville NY 14221 ASC Cover Letter w Physical Exam Protocol 11/2016
American Steamship Company/Liberty Steamship Company 2019americansteamship.com/pdfs/2019/2019 ASC Physical... · 2019. 1. 3. · CG-719K (04/17) Previous Editions Obsolete Page 2
